Provider Demographics
NPI:1073870515
Name:KANZLER, TIFFANY MARIE
Entity Type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:MARIE
Last Name:KANZLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 N WALNUT ST
Mailing Address - Street 2:UNIT 2 B
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-2884
Mailing Address - Country:US
Mailing Address - Phone:386-214-7525
Mailing Address - Fax:
Practice Address - Street 1:805 N WALNUT ST
Practice Address - Street 2:UNIT 2B
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-2884
Practice Address - Country:US
Practice Address - Phone:386-214-7525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11852224Z00000X
IL057003617224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant